They were warned

Young people may be harmed as a result of Germany's new treatment guideline

Photo by Tiago Bandeira on Unsplash

Florian Zepf

The new S2k German-language guideline—on Gender Incongruence and Gender Dysphoria in Childhood and Adolescence: Diagnosis and Treatment—has been finalised and published. It has undergone a few changes since the draft release in March 2024, but most of these adjustments have been rather minor.¹

One very recent change is that the guideline now suggests clinicians distinguish between stable “gender incongruence” and temporary “gender non-contentedness” in minors, but it doesn’t give any specific criteria on how to differentiate these two groups in advance—nor is it clear with what validity this actually could be done. In making this novel distinction, the new guideline uses a flawed line of reasoning and ignores important evidence.

We know from a recent study of health insurance data that even when the diagnosis of gender incongruence is believed to be correct by the clinician, it still does not persist in the majority of cases just a few years later. After five years, only 36.4 per cent still had a confirmed diagnosis, and a diagnostic persistence lower than 50 per cent was detected across all the age groups studied (27.3 per cent for 15-19-year-old females, and 49.7 per cent for 20-24-year-old males).

Therefore, the entire line of argumentation as to which minors should receive puberty blocking medications and/or cross-sex hormones is based on an unclear differentiation that cannot be applied in clinical practice.² There are no valid criteria that one could use to adequately identify these particular groups in advance, and gender incongruence as a diagnosis in young people is not as stable as outlined in these guidelines.

It is noteworthy that some newer literature on the use of puberty blockers and cross-sex hormones in minors affected by gender-related problems has now been referenced in the newly published guideline, and this was a point of critique in the past. However, key elements of the guideline’s critical recommendations regarding the use of these puberty blocker medications and cross-sex hormones in affected minors have not been changed in accordance with the evidence cited.

The recommendations on puberty blockers and cross-sex hormones in these vulnerable young people do not adequately reflect the reality that there is still no clear and reliable evidence that the use of these interventions in minors with such gender-related issues leads to credible, long-lasting, and substantial improvements. In fact, we know that potential harms can occur. As a consequence, at the current stage, this particular approach in terms of using puberty blockers and cross-sex hormones in affected minors must be regarded as experimental.

A further point is the notion in the guidelines that if parents and their children disagree about such medical interventions for the child, then an independent legal review should determine which approach is in the best interests of the child. In Germany, this could potentially mean that children be taken out of the custody of their parents or that parents lose the right to make medical decisions for their offspring, depending on the outcome of such an assessment and the underlying (potentially false) assumptions feeding into such a review.

However, from a medical point of view, at this stage it is unclear what the best interests of such a child would actually entail, and the largely “pro-affirmative” approach as suggested in the new guideline gives reason for concern in this context. In particular, the guideline seems to be constructed around the false assumption that in every child there is a ubiquitous and immutable gender identity that is completely independent of the biological sex, and with this identity being naturalistically predetermined. This is an unproven scientific assumption which ignores the fact that adolescents’ views of themselves are often self-interpretations, and a clear distinction between such self-interpretations and aspects of identity cannot be made with sufficient validity.

It is a well-known fact that self-interpretations of minors often evolve over time—a characteristic feature of child and adolescent development. This is also the reason why an open-minded psychotherapy offered to these young people shouldn’t automatically be labelled as unethical “conversion therapy.” Such open-minded psychotherapy aims to explore the reasons for gender-related symptoms as part of a larger picture, which can have various origins (partially, also, in the context of potentially accompanying psychopathologies up to co-occurring psychiatric disorders). Another argument against an automatic accusation of conversion therapy is that this expression implies the young person is converted away by psychotherapy from something that is immutable, ubiquitously defined and naturalistically predetermined.

For these reasons, the new S2k guideline has the potential to significantly harm vulnerable children and adolescents with gender-related problems. Many of the recommendations in the guideline are not evidence-based, stand on shaky ground and can thus create a lot of damage in vulnerable minors.

As a group of 15 German professors working in the field of child and adolescent psychiatry, psychosomatics and psychotherapy we have recently published a detailed analysis of the guideline draft from March 2024, and the Society for Evidence-based Gender Medicine has also conducted a thorough examination of the draft document and has outlined important methodological flaws.

The group-of-15 joint commentary on the guideline contains a point-by-point response over 111 pages to all aspects of this particular document, and was submitted to the German Society for Child and Adolescent Psychiatry and Psychotherapy and to the respective guideline development group. This means that the guideline group has been aware of these flaws, and yet the decision was made to publish the final but insufficiently adjusted document. In particular, the adjustments made do not reflect the weak state of the current evidence.

It will be difficult to defend these actions in the future as all the arguments and critiques were openly available. We hope that our joint commentary can equip vulnerable minors and their families with important information should they become victims because of damage received by interventions that were promoted through these guidelines.

In summary, clinicians, families and young people affected by gender-related problems need to be aware that the new German guideline has significant flaws and includes recommendations that could potentially lead to harm. In Germany and also internationally, there is a strong and heated debate on how to provide the best support for these vulnerable children and adolescents.

The new guideline in question does not meet the necessary evidence-based standards to adequately support young people facing these challenges. A large number of professors, doctors, psychologists, psychotherapists and other clinicians in the field of child and adolescent psychiatry, psychosomatics and psychotherapy and related professional areas in Germany consider these guidelines as highly problematic, and many are unlikely to adopt them.

It is still not too late to withdraw these guidelines and revise them in the light of actual medical evidence. The responsibility for addressing these serious shortcomings and upholding the fundamental medical principle of “First, do no harm” rests with those who developed and approved this very problematic guideline.

Florian Zepf is Chair Professor and Clinical Director of the Clinic of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy at Jena University Hospital, Germany. He was a member of the S2k guideline group from mid-2020 until November 2022, and left because of his professional and ethical concerns about the emerging document. Professor Zepf was first author of the group-of-15 critique and of an updated systematic review of the evidence for using puberty blockers and cross-sex hormones in minors with gender incongruence and gender dysphoria.

1. GCN’s news report on the German guideline is here.

2. One might argue that eligibility for these treatments should be limited to those patients characterised by the new guideline as having stable gender incongruence rather than temporary gender non-contentedness.